How Nigeria Defeated Ebola
How Nigeria Defeated Ebola
by Kristin Peterson, Morenike O. Folayan, and Aminu Yakubu
Ada Igonoh was the physician who pronounced Patrick Sawyer dead. Four days after he had been admitted to First Consultants Medical Centre, she found him collapsed and nonresponsive in his private hospital bathroom. That day, no one was allowed near the door until World Health Organization officials took the body away. On the day he died, July 24, 2014, an evaluated blood sample confirmed everyone’s worst fears. Ebola had arrived to Lagos, Nigeria – the largest city on the African continent.
At that time, Ebola infections had dispersed for eight months across the Mano River region states of Liberia, Sierra Leone, and Guinea, where the December 2013 Ebola outbreak began. None of these countries’ heads of state had yet to declare a medical crisis needing urgent attention. Neither had the WHO. But the traveller who left Liberia and died in Africa’s most populous country led Nigerian officials to instantly declare a national state of emergency. They immediately began managing a potentially catastrophic situation, one that would catch the infectious disease world by surprise.
In Nigeria, there is a critical mass of scientific, medical and public health expertise. They possesses decades of experience managing medical crises, natural disasters, and the health-related fallouts of long-term economic breakdown driven by international financial institutions. Bypassing a highly underfunded health care system and a global racial divide when it comes to accessing medical treatment, Nigerian personnel set up an emergency response unlike any other implemented in the past. Their efforts resulted in one of the highest survival rates in Ebola outbreak history.
* * *
A naturalized US citizen living in Coon Rapids, Minnesota, the 40-year old Sawyer was in his former home country of Liberia working for ArcelorMittal, a Luxembourg-headquartered, multinational steel manufacturer. There were about 100 people infected with Ebola in Liberia including his younger sister, Princess Christina Nyennetue. Sawyer was with her at St. Joseph Catholic Hospital the day before she died on July 8. After insisting upon an autopsy, the cause of her death became known. ArcelorMittal got word that Sawyer was in contact with a family member infected with Ebola and insisted that he turn himself over to the Ministry of Health for screening. The virus has a 21-day incubation period and he was relieved from work for a “clinical watch.”
But on Sunday, July 20, 2014, 11 days into isolation, Sawyer flew from Monrovia, Liberia to Lagos, Nigeria. His intention was to fly onward to the eastern city of Calabar, where he would attend an Economic Community of West African States (ECOWAS) conference. Although reports vary, it appears he was representing the Liberian Ministry of Finance as a consultant. On his Asky Airlines flight, Sawyer became severely ill. When he arrived at the Murtala Muhammed International Airport in Lagos, he collapsed in the terminal. Two ECOWAS officials, Mr. Jatto Abdulqudir and Mr. Koye Olu-Ibukun, were waiting and quickly decided to get him medical attention. But Nigerian physicians working in public hospitals were knee-deep in a national strike. All public health facilities were closed to patients. The private hospital, First Consultants Medical Centre, remained open and was Sawyer’s best option.
Sawyer told the intake physician that he had just flown in from Monrovia. But he denied being exposed to Ebola. He was feverish and so the physician ordered a full blood count and tested for malaria, which is endemic to West African countries. That night, all blood work came back normal. By the next morning his condition was significantly worse. HIV and hepatitis tests were conducted and both turned out to be negative. After two days of no definitive medical explanation, Dr. Stella Ameyo Adadevoh, the attending physician in charge, decided it was time to screen for Ebola and notify health authorities.
Ebola is not endemic to Nigeria and therefore, not common for a hospital to have clinical tests for EVD in stock. And so Dr. Adadevoh contacted Professor Abdulsalami Nasidi, the Director of the Nigeria Centre for Disease Control, located in the country’s capital, Abuja. Nasidi referred her to the Department of Virology at the Lagos University Teaching Hospital (LUTH). It recently received testing kits for Ebola from research colleagues in Germany. Coincidently, when Dr. Adedovah called, Professor Nasidi was preparing to fly to Lagos in order to chair an already-scheduled academic meeting on Ebola at the West African College of Physicians. Little did he realize that he would be staying in Lagos for the next six weeks in full crisis-mode.
Before she prepared blood and urine samples to be sent to LUTH that day, Dr. Adadevoh searched for Ebola information online. She created information packets that contained transmission and prevention measures and distributed them to all the staff. This was First Consultant’s own self-taught crash course training on EVD management. Faced with no Ebola-specific personal protective equipment that covers clothing, skin, and provides a barrier to body fluids, they used only what they had on hand: gloves, shoe covers, facemasks. The staff erected a wooden barricade at the entrance of Sawyer’s room because they had no other way to isolate the patient.
On the third day of his hospitalization, Sawyer asked to see a physician. Dr. Igonoh gowned up and went to him. She discovered he was experiencing very severe dysentery. She found his IV bag on the floor, which she picked up and hung back on its stand. After instructing the nurse, Justina Ejelonu, to attend to the patient, she updated her supervisor, Dr. Adadevoh, on his condition. Mr. Abdulqudir, the ECOWAS official, was at the hospital. He approached the two physicians and reminded them that Mr. Sawyer needed to be on a morning flight to Calabar. “Is it possible for him to be discharged?” Mr. Abdulqudir asked. No, it was not, Dr. Adedovah adamantly explained.
It was never clear why there was such an urgency to get Sawyer to the conference. Liberian journalists were perhaps the first to raise questions. They obtained security footage from the Payne International Airport in Monrovia where they observed Mr. Sawyer at his departure gate. In their reports they claimed that he avoided coming in contact with anyone, and at one point, laid belly-down on the floor in a corridor. He seemed to be in excruciating pain. The urgency to get on that plane to Lagos was met with an equal pressure to move him on to Calabar: the hospital received several calls from ECOWAS and Liberian government authorities who insisted that Sawyer be discharged. Journalists would later press government officials on their own behavior. A clear response never materialized, but ultimately a dead man was accused of dishonest communication with government representatives.
Dr. Adedovoh was the lead hospital physician responsible for resisting outside pressures to release Mr. Sawyer when Ebola suspicions arose. Along with nurses, she also had to physically restrain him as he became increasingly hostile to isolation and treatment. Dr. Adadevoh (mostly) confined Ebola to First Consultants Medical Centre, keeping it from moving into the third fastest growing city in the world that is home to 21 million people – a population larger than the combined total inhabitants of the three hardest Ebola-hit countries in the Mano River region. It was a prospect that could have rescaled the entire history of the world’s disease outbreaks.
* * *
The day before Patrick Sawyer died, Nigerian scientists gathered at the West African College of Physicians for the Ebola academic meeting. To their shock, Professor Sunday Aremu Omilabu, head of the Virology Department at LUTH and Professor Nasidi announced that a foreigner who travelled to Nigeria tested positive for Ebola. Yet with the outbreak scaling up in Liberia, Sierra Leone, and Guinea, the scientists in the room knew it was only a matter of time, given the porousness of West Africa’s borders. As a citizen of an ECOWAS state, one can legally cross the vast rural state boundaries without visas and passports. Along the 350-mile border of Liberia and Guinea, for example, there are countless free points of passage. People circulate for trade, work, mining, weddings, burials, family gatherings, and fun, every day. These rural areas comprise a dense network of cross-border activities, and some are systematically unregulated.
Like its West African neighbors, some of Nigeria’s rural borders are also unregulated. If Ebola were to enter Nigeria through one of these, it could take weeks to detect. In the past, other disease outbreaks in the country like cholera, polio, meningitis, and even the endemic hemorrhagic Lassa fever, often get discovered in remote areas once they become a crisis. Another huge concern for scientists and government health officials was the urban border of Lagos and its surroundings. The ancient slave port of Badagry, a town at the edge of Lagos state, is a major transport depot to cities all over West Africa. Everyday, thousands if not tens of thousands of people travel to and from this place. The fear that Ebola would arrive overland in this manner had everyone worried. But for the most part, the 2013 Ebola outbreak did not disperse outside of the Mano River region by those traveling on foot or by bus. Rather Ebola accompanied elites – the wealthy, business people, and international health emergency workers – on international flights. Characterizing the sheer luck of this hypervisibility, a health official told us, “Ebola arrived to Lagos screaming.”
In April 2014, three months before Patrick Sawyer died, clinicians and research scientists affiliated with the National Institute for Medical Research and the Lagos State Ministry of Health began to pre-emptively educate and train government health officials at the Lagos port and rural borders. They also trained doctors and medical workers on case definitions as well as lab preparation. They held public meetings and disseminated information to “every nook and cranny of Lagos State and eventually the whole of Nigeria,” said Dr. Jide Idris, the Lagos State Health Minister.
“We still had to come to people’s level – at least to listen to them about their fears and challenges on Ebola,” said Dr. Francisca Nwaokorie, a medical laboratory scientist specializing in microbiology and parasitology at the University of Lagos. The biggest question at public meetings was whether Ebola could be cured. Since it cannot be treated with medication, the stress was on prevention measures. The public meetings were particularly beneficial to parents concerned about their kids’ safety at school. Dr. Nwaokorie explained, “there was one school where I gave a lecture. When I came around a second time, school administrators had already mounted a massive water system, where everyone can go to wash their hands. And actually some parents volunteered to get that done.”
But there was still a lot to do once the outbreak started. The teams utilized the skills of small town announcers who, in very charismatic ways, disseminate information. Multimedia campaigns were launched like the series Lens on Ebola, produced collaboratively by Lagos-based health-media organizations, US Centers for Disease Control and Prevention, and ‘Nollywood’ film companies and movie stars. Eventually, community development organizations, mosques, churches, traditional leaders and schools were all involved in the campaigns.
Despite the shock and the panic, these scientists and health officials had been prepared for an Ebola outbreak. At that July 23 meeting, Professors Omilabu and Nasidi were expected to lead an academic discussion of Ebola as a clinical disease. But with the information about Sawyer’s positive Ebola test, they launched the beginnings of a nation-wide emergency Ebola response. Some of the scientists and clinicians in attendance were the first to volunteer in containing the outbreak.
* * *
The morning after Patrick Sawyer died, First Consultants Medical Centre went into emergency-mode. The hospital was decontaminated after every patient was discharged and put on an Ebola clinical watch. Dr. Ada Igonoh said that all the hospital workers began to retrace not just their contact with Sawyer, but all their interactions including handling patients and lab materials, the usual and intimate familiarities with each other, and how they touched their children on the nights that Ebola was not yet suspected.
The next day on Saturday, July 26, all the First Consultant staff met with Prof Nasidi, Prof Omilabu, Dr. Idris, and other key health officials. After being congratulated on how well they handled the situation, they were grouped into high and low risk categories based upon their exposure to Sawyer, who was now being called the “index patient.” “Each person received a temperature chart and a thermometer to record temperatures in the morning and night for the next 21 days,” Dr. Igonoh explained in her own written account of the ordeal. “We were all officially under surveillance. We were asked to report to them at the first sign of a fever for further blood tests to be done. We were reassured that we would all be given adequate care. The anxiety in the air was palpable.”
Dr. Igonoh was exhausted from the week’s events and decided to get out of the intensity of Lagos – a city whose frenetic tempo makes New York feel like a sleepy village. She stayed with her parents just outside the city where on Tuesday, July 29, she developed joint and muscle pains and a sore throat. She decided these were due to stress and anxiety. She took medication for suspected malaria and antibiotics for the sore throat. “Every day I would attempt to recall the period Patrick Sawyer was on admission—just how much direct and indirect contact did I have with him? I reassured myself that the contact with him was quite minimal.” After she completed the 3-day anti-malarial treatment, the aches and pains persisted. She lost her appetite and was extremely fatigued.
On Friday, August 1, Dr. Igonoh woke up, greeted her parents, and took her temperature. It was one of those slow motion moments that heightened her anxiety beyond anything that she experienced in the previous two weeks. She informed her mother that she had a fever and isolated herself from the family. The next morning, August 2, her sore throat persisted and the fever was even worse. She immediately called the Ebola helpline and an ambulance was sent with WHO doctors on board who took blood samples. Later in the day, dysentery and vomiting began. She remained isolated from her family who was convinced that she didn’t have Ebola.
On Sunday, August 3, Dr. Igonoh got a telephone call from one of the WHO doctors who took her blood. Another sample was needed. An ambulance arrived but the clinicians on board did not draw blood as they did the day before. Instead they asked her to go back with them to a temporary isolation center that had been set up by the Lagos State Government. It was located at the public Mainland Hospital in the Yaba neighborhood of Lagos. There, she was told, someone with more skills would draw her blood. “Will you bring me back home?” she asked. Yes, they would bring her back that night. Her mind raced. In that instant, and nearly every waking hour since Sawyer’s death, she recalled over and over the times that she had contact with him. Every interaction was minimal including when she felt for his pulse, through double-gloved fingers, at the time of his death.
Dr. Igonoh told her parents that she was going to Yaba and would be back in the evening. The 26 year-old physician got dressed in a white top and a pair of jeans. She put her iPad and three mobile phones in her purse. The driver opened the door and kept his distance. From the bedroom window, her mother watched the ambulance drive off to the city. Upon arriving to Yaba, Dr. Igonoh was instructed to stay put; she was offered food but couldn’t eat anything. After four hours of waiting, the ambulance door opened. An unfamiliar white man appeared and said to her, “I have to inform you that your blood tested positive for Ebola. I’m sorry.”
* * *
“We had gone to Obudu on a trip for our polio program. That was the week of July 13th. We came back on the 21st; and on the 22nd was when we started hearing rumors. Ebola was confirmed on 23rd. And on the 24th, it was panic.” Dr. Patrick Nguku is a surgeon and medical epidemiologist by training. He has previous experience combatting disease outbreaks in East Africa including Ebola in Northern Uganda. As the Resident Advisor of the Nigeria Field Epidemiology and Laboratory Training Programme in Abuja, he is responsible for training public health experts in conducting disease surveillance and responding to disease outbreaks. In the past, this agency tracked and coordinated responses to cholera, meningitis, Lassa Fever and other diseases.
The first task for Dr. Nguku’s team was to tediously comb through the hospital records at First Consultants. After examining the files, inpatients and outpatients were categorized into high and low risk categories just like the hospital workers. “Initially there were 9 people to follow up but then we went back and realized there were 40. Then the list expanded to 70, so we had to design a system on how to make sure that in the context of fear – and there were a lot of fear at that time – that we follow everybody without necessarily scaring them, without necessarily making them go underground.”
Physicians can see over a hundred of patients a day. Medical personnel are not often available to provide extensive comfort or food to patients even in private hospitals. This means that hospitals often rely heavily upon family members and friends to feed, clean, and even secure medicine for their ill loved ones. Dr. Nguku’s team had to also consider the fact that there are just as many, if not more, visitors than patients inside hospitals at any given time. Essentially it was the team’s job to identify and determine the status of every single person – patient, visitor, worker – who entered the hospital during Patrick Sawyer’s hospitalization.
The enormity of this work was only the first stage of what public health officials commonly refer to as “contact tracing” – finding everyone who was in contact with an Ebola patient. The parallel task was to coordinate tracing everyone who had come into contact with Sawyer from the moment he landed up until his arrival at First Consultants. Dr. Nasir Sani-Gwarzo, a medical epidemiologist and director of the Port Health Services Division of the Ministry of Health, headed a team that evaluated airline passenger lists. They had to identify whom Sawyer may have been in contact with on the plane, at the airport, and even those who flew out of Nigeria that day. They decontaminated the airport and established entry and exit screening at all ports of entry throughout the country.
In retracing events, Drs. Nguku and Sani-Gwarzo’s teams had to imagine that after deplaning, Sawyer stood in a long immigration line. He eventually handed his passport back and forth to at least two government officials. He then waited with other passengers from different flights at the baggage claim. When he met his ECOWAS contacts, Mr. Abdulqudir and Mr. Olu-Ibukun, they walked past the hundreds of passengers and visitors moving up and down the terminal. After exiting the airport, they made their way through numerous currency sellers wanting to change their money. Then they walked among the multitudes of taxi-drivers attempting to secure the lucrative deal of driving them to another part of the city. At some point, someone had to pick Sawyer up off the floor after he collapsed.
At least an hour ride by car, Sawyer, Abdulqudir, and Olu-Ibukun traversed the constantly pumping street activity of Lagos. The three men drove through dense traffic and numerous neighborhoods where human determination is constantly stretched in an effort to “make it” in the city. At the airport exit, where many people mingle and do petty trade, they stopped to pay a parking fee. Once outside the airport, they drove along Airport Road where they passed the Ikeja General Hospital whose workers were on strike. More than likely they got stuck in a “go-slow” – a traffic jam that usually forms in front of Computer Village, West Africa’s largest secondhand market specializing in imported electronic goods. In this highly commercialized section of Ikeja, a dense amount of foot traffic moved alongside as well as between all the vehicle lanes while the latest Nigerian hip hop and popular hits blasted from the stores into the street.
Making their way out of Ikeja, they more than likely encountered another hold up at the Maryland Roundabout, one that was punctuated with melodic car horns navigating the congestion. At all hours, a mobile market literally appears and disappears with the traffic itself. Young men and women eking out a living move up and down the go-slow. They repetitively call out “pure water!” and other items they’re selling like cold soft drinks, groundnuts, fruit, jewelry, cigarettes, rat poison, books, toilet seats, inspirational Christian literature, Korans, packaged snacks, newspapers, credit for mobile phones, kitchen appliances, household goods, nutritional supplements, novels, and so much more. Nguku’s team had to imagine whether the usual exchange between sellers and passengers could have taken place between rolled down vehicle windows.
If Mr. Abdulqudir did not continue driving down the eight lane Ikorodu Road past the neighborhoods of Ilupeju, Palmgrove, Ojuelegba, and Surulere, then most likely they took the 7.3 mile (11.8 km) long Third Mainland Bridge, the second longest in Africa. Driving high above the west side of the Lagos Lagoon they passed over Makoko – a neighborhood that the London Guardian dubbed “the world’s largest floating slum” in contrast to Adolphus Opara, a Nigerian photographer, who calls it the Venice of Africa. Beneath the bridge nearly 100,000 residents live in small wooden homes that sit just above watery thoroughfares. Makoko provides its residents slim opportunities for exhausting labor and the constant threat of eviction by city officials.
As the three continued, they approached skyscrapers towering above elite Lagos neighborhoods. When Third Mainland Bridge emptied into the island city, they found themselves in one of Africa’s largest markets located in the precolonial neighborhood of Idumota where Yoruba indigenes and descendants of 19th century Brazilian slave returnees reside. Moving through Lagos Island, Sawyer, Abdulqudir, and Olu-Ibukun passed through the hustle and bustle of widespread commercial activity that moves effortlessly between wholesale businesses and the streets; where laundry hangs on the various layers of city infrastructure; where church services are performed in front of small businesses; where snazzily-dressed elite professionals and the working class stand in line to eat regional specialties at small, delicious food joints; where folks lay their bets on Nigeria’s volatile economy; where many unreachable dreams are put to test.
Exiting off the island’s main Ring Road, they arrived at the Obalende roundabout, one of the city’s largest transport depots, where buses vie for lucrative parking as well as customers travelling to every corner of the city. Folks mingle and sell food and other goods in a market that draws on would-be passengers. There, the three men parked and stepped down from the vehicle. Together they moved through some of the island’s densest foot traffic to the entrance of First Consultants Medical Centre.
After Patrick Sawyer died, the emergency response teams had to consider the possibilities of an Ebola-infected traveler making a drive like this from the northern edge of the Lagos metropolitan area to its Southern most tip before receiving medical care. The ride, the airport passengers, the visitors to the hospital, and the numerous people with whom they all had contact along the way, all had to be considered on that first day of Nigeria’s national emergency response.
* * *
“I really had no clue where I was. I knew it was a hospital. I was left alone in the back of the ambulance for over four hours. My mind was in a whirl. I didn’t know what to think.”
The WHO physician who met Dr. Igonoh in the ambulance instructed her to open her mouth wide. “He said it was a typical Ebola tongue. I took out my mirror from my bag and took a look and was shocked at what I saw. My whole tongue had a white coating, looked furry, and had a long, deep ridge right in the middle. I then started to look at my whole body, searching for Ebola rashes and other signs, as we had been recently instructed. I called my mother immediately and said, ‘Mummy, they said I have Ebola. But don’t worry, I will survive it. Please go and lock my room now; don’t let anyone inside and don’t touch anything.’ She was silent. I cut the line.”
Dr. Igonoh was then taken to the female ward of a temporary isolation center set up by the Lagos State Government. To her, it looked like an abandoned building that hadn’t been used in a while. There was one other patient in the ward – a nurse assistant from First Consultants, Mrs. Ukoh – whose symptoms were worse than her own. She got settled and began what would be weeks of getting used to the stench of feces and vomit, and also what she would think of as the “Ebola smell” that lingered in the air. The two women were served rice and tomato-based stew that night but neither of them ate.
Dr. David Brett-Major, the World Health Organization physician who greeted her in the ambulance, came in wearing goggles and a full protective hazardous-materials – hazmat – suit, an impermeable chemical and mircrobial whole-body garment. It was the first time that she had seen it in person. Before that she had only seen images of them online. He brought her several bottles of water as well as oral rehydration fluid therapy (ORS), which he dropped by her bedside. He informed Dr. Igonoh that she had to drink at least 4.5 litres of oral rehydration fluid daily to replace fluids lost to diarrhea and vomiting. After they finished talking about her treatment, he said good night and left.
Then, “My parents called. My uncle called. My husband called crying. He could not believe the news. My parents had informed him, as I didn’t even know how to break the news to him. As I lay on my bed in that isolation ward, strangely, I did not fear for my life…There was an inner sense of calm. I did not for a second think that I would be consumed by the disease.”
But that evening, the symptoms fully kicked in. She had diarrhea every two hours. She would run to the toilet with a bottle of ORS, so that when she was stooling, she was also drinking. The toilet in the makeshift isolation center did not flush and had to be cleared by pouring a bucket of water through it. She placed another bucket next to her bed for vomiting. The next morning, August 4,th she noticed red rashes on her skin. She had developed sores on the inside of her mouth. Her throat was so sore that she could not eat; she could only drink ORS. She took paracetamol (aspirin) and nothing else for the pain. Mrs. Ukoh, lying across from her, had stopped speaking.
It was nine days after Patrick Sawyer died. On the outside, public health officials were still frantically organizing the emergency response. Inside the isolation ward, there was a desperate need to change bed sheets and mop the floor. At this early stage, only Dr. Brett-Major entered the ward to see them, chat, and clean up. No one else came. Cooks on the compound fixed their meals and left them outside the door. It was a new experience, everyone was scared and learning how to cope.
Later that evening, Dr. Brett-Major brought another patient into the ward, Justina Ejelonu, a nurse who began working at First Consultants the week before. The night that Sawyer’s worst symptoms kicked in, Mrs. Ejelonu was on duty and attended to him. In a fit of resistance, Sawyer snatched off his IV drip and blood flowed like water out of a faucet into her bare hands. She developed symptoms at home. When she and arrived at the isolation ward, she was bleeding from an in-progress miscarriage. The following day Mrs. Ejelonu tested positive for Ebola. She was devastated. Not only did she lose the baby but she also contracted Ebola on the first day at her new job.
Dr. Igonah’s pastor called her to offer spiritual support. He is also a physician and “encouraged me to monitor how many times I stooled and vomited each day and how many bottles of ORS I consumed. We would then discuss the disease and pray together. He asked me to do my research on Ebola since I had my iPad with me, and told me that he was also doing his study. He wanted us to use all relevant information on Ebola to our advantage. So I researched and found out all I could about the strange disease that had been in existence for 38 years.”
They discovered that there are five viral strains of Ebola Virus Disease. Dr. Igonoh had the deadliest of them – the Zaire strain. They found that patients who die of Ebola usually do so anywhere between 6 and 16 days after the onset of symptoms that lead to multiple organ failure and system shock caused by dehydration. “I read that as soon as the virus gets into the body, it begins to replicate really fast. It enters the blood cells, destroys them and uses those same blood cells to aggressively invade other organs where they further multiply. Ideally, the body’s immune system should immediately mount up a response by producing antibodies to fight the virus. If the person is strong enough, and that strength is sustained long enough for the immune system to kill off the viruses, the patient is likely to survive. If the virus replicates faster than the antibodies can handle, however, further damage is done to the organs.”
Dr. Igonoh was past the first stage of symptoms – headache, fever, muscle soreness, which usually occurs within the first 7-9 days after initial infection. She was experiencing symptoms that are typical of “second stage” Ebola. The third stage includes bruising, brain damage, and bleeding from the nose and mouth. At the fourth and final stage, one loses consciousness, experiences seizures, and eventually dies from mass internal bleeding. Moving from one stage to the next can take place within days or within a matter of hours. “I had no intention of letting the deadly virus destroy my system. I drank more ORS. I remember saying to myself repeatedly, ‘I am a survivor, I am a survivor.’
* * *
The day that Patrick Sawyer tested positive for Ebola, federal and Lagos State health ministries activated the federal Emergency Operations Center (EOC). It was made up of an interagency team including the Nigeria Institute of Medical Research, National Primary Health Care Development Agency, the Nigeria CDC, Lagos State Government (which had its own EOC too), Federal Tertiary Hospitals, the Red Cross of Nigeria, and some foreign partners.
Dr. Faisal Shuaib, a physician and public health expert, was in charge of it. It used an Incident Management System, which is a hierarchically coordinated reporting structure. The Minister of Health is at the top. He communicates with Dr. Shuaib, the Incident Manager, the Nigerian Centers for Disease Control, and importantly, the national media, which was harnessed extensively for daily updates. Feeding up the chain were six components of the emergency response that were granted autonomous and flexible decision-making: epidemiology and surveillance, case management and infection control, social mobilization, lab services and diagnostics, and borders and management coordination. Built into the EOC was a platform to interface with the medical community within and outside of Nigeria so that hour-to-hour regional Ebola updates were immediately available to the staff. Foreign partners like Médecins Sans Frontières (Doctors Without Borders), WHO, U.S. CDC, and UNICEF were assigned to different response teams based upon experience and know-how. They worked under the direction of Nigerian officials and with their Nigerian counterparts.
The EOC had been in place since 2012. It originally focused on wiping out wild poliovirus, which was otherwise nonexistent throughout the rest of the world, except for Pakistan and Afghanistan. The EOC represents the need for an emergency approach to combatting polio because the national health care system was in a long state of decline. The critical event that severely debilitated Nigerian public health was the 1986 International Monetary Fund’s “structural adjustment program,” which forced Nigeria to privatize its markets and state systems. In protest, millions of Nigerians from the village to the city took to the streets. The IMF and the Bank worked closely with military dictatorships, which brutalized a largely resistant public in order to force through highly unfavorable reforms. While structural adjustment was meant to abate national debt and other macroeconomic problems, it severely weakened the national economy, which had negative impacts on all aspects of Nigerian life. The health care system became difficult to access because privatization measures led to expensive care, supply shortages, lowered salaries, and medical workers bolting to more lucrative posts.
Perhaps even worse, in Sierra Leone and Liberia – two of the hardest hit Ebola countries – structural adjustment was directly connected to the onset or exacerbation of horrifying civil wars. These wars’ aftermaths left health care systems all but collapsed with medical workers fleeing for their lives in what amounted to massive brain drains. After a decade of reforms and conflict, Ebola broke out in Sierra Leone when only about 245 doctors were left in the country.
By the mid-1990s, Nigeria was not only rocked by a severe economic crisis, but a severe health crisis, which has not abated. The national delivery of vaccines was especially impacted. The federal Ministry of Health devolved national vaccination responsibility to state governments, which did not have the budgets to carry out their mandates. By 2003, official estimates indicate that only 30% of the child population was getting routinely vaccinated. Preventable diseases, like polio, were rapidly resurfacing as a direct result of economic austerity programs. While southern Nigeria had all but eliminated polio by the early 2000s, the North – a vast Sahel region that is home to extreme wealth inequality and extensive withdrawal of state health funds – still harbors many polio infections. Over time, the polarization of the haves and the have-nots in the North became one of the greatest social divides on earth.
In 2003, the vaccination campaign unexpectedly faced a widespread boycott. Rumors began to circulate that the vaccine contained HIV, cancer stimulators, and anti-fertility drugs meant to wipe out the majority Muslim population. These inaccuracies were fuelled by political struggles between Northern political and religious leaders and a newly elected federal civilian government hailing from the Southwest. In many ways, these divisive struggles mirrored a chronic political holdover of British colonialism, where elite Northerners were favored by the British during the colonial era.
Community suspicions arose because it appeared odd that after years of not being able to access basic medical care, health workers suddenly appeared in droves offering free polio vaccinations in remote areas. Further perceived evidence of a suspected conspiracy emerged between 2005-10 when over 300 children became paralyzed after being vaccinated. When the boycott disrupted the polio campaign, there were large areas that went unvaccinated. Immunity depends upon high vaccination rates and the low number of polio immunizations led to a vaccine-induced outbreak. For much of the public, the outbreak confirmed the rumors that the vaccines were trouble.
Moreover, the north was the site of a scandalous clinical trial orchestrated by the world’s largest pharmaceutical company, Pfizer. In 1998, a widespread meningitis outbreak appeared in the northern city of Kano, where over 100,000 people piled into hospitals seeking treatment. Alongside Médecins Sans Frontières, which was administering emergency care, Pfizer set up a clinical trial to see if its existing marketed drug, Trovan, could be extended to treat children with meningitis. Emergency medicine and experimental research bled into each other, which caused confusion among those seeking medical relief. The trial was never registered with the national drug regulatory agency essentially making it illegal. A total of eleven children died and many more were maimed. The same time that rumors circulated about the polio vaccine, citizens in northern Nigeria witnessed the Pfizer suit being filed in and thrown out of courts across continents, which was widely reported in the Nigerian media. The release of Wikileaks documents indicate a backroom deal was made between Pfizer and the Nigerian government that settled for substantially less damages than what the plaintiffs were seeking. The lack of delivered justice further legitimated rumors of a tainted polio vaccine by a public who clearly knew where it stood when it came to pharmaceutical geopolitics.
The Polio EOC recognized that the challenges it faced were political and had little to do with the usual technical aspects of vaccine delivery. Workers intensified infant immunization, assisted with the health of mobile populations, and educated communities on vaccination in very insecure areas. But in 2013 nine female vaccinators were shockingly assassinated in the northern city of Kano. The terrorist group, Boko Haram, was accused of the attacks but no suspects were identified.
In the face of these devastating events the EOC continued working and, against all odds, eliminated polio just months before Ebola arrived to Nigeria. At that point, Dr. Faisal Schuaib oversaw a repurposing of the EOC’s operations, which moved from Abuja to Lagos. Forty EOC staff physicians stayed on and their expertise was morphed from managing polio to managing Ebola. Dr. Schuaib helped to scale up donations from the Nigerian government ($11.5 million) and private domestic and international donors. For the most part, funds quickly arrived to support a coordinated Lagos State infrastructure already in place.
Like the EOC, the Lagos State government had its share of dealing with horrific medical emergencies. In the last 15 years, it responded to two different airplane crashes in densely populated neighborhoods, a massive weapons explosion at the Ikeja military cantonment near the airport, oil pipeline explosions, floods, cholera outbreaks, and H1N1. As Lagos State Minister of Health Dr. Idris would later put it, these previous disasters and the state’s emergency management experience provided “the templates and mechanisms for interstate, intergovernmental and international collaboration.” Federal and state officials are often accused of not working well together in Nigeria especially when governed by two opposing political parties, as was the case between Lagos State and the federal government. But these administrators quickly merged two existing systems of disease surveillance and community mobilization. Staff volunteers were recruited and trained for higher pay and guaranteed life insurance. It ultimately took an emergency paid-volunteer workforce of 2600 Nigerian health experts to make it all work.
From experience, these workers knew that the immediate task at hand was to not deny or deplore the fear and stigma arising with the frightening prospects of a disease outbreak. They knew that such reactions are filtered through the long-term fall-outs of structural adjustment and British colonialism bearing down on epidemiology.
* * *
Just after the nurse, Justina Ejelonu, arrived to the isolation ward, Mrs. Ukoh, the nurse assistant, died on August 12. The women inside the isolation center were shocked and saddened; they waited 12 hours before WHO authorities removed the body. The bed sheets and mattress were burned and the entire area scrubbed down with disinfectant. The mood was severely dampened especially after also hearing the news that Mr. Abdulqudir, one of the men who retrieved Patrick Sawyer from the airport, died the same day in the men’s ward. Despite the fact that patients inside the female and male wards were getting outside support – prayer circles, phone calls, and the delivery of medical supplies especially from the chief medical director of First Consultants, Dr. Benjamin Ohiaeri – they were under immense emotional strain.
In anticipating the need for psychosocial support, the EOC recruited psychologists, medical psychiatrists, and social workers. One of the patients in the ward was “Mr. James” (a pseudonym). Three weeks after his admission, James was confused, sleeping poorly, acting unruly, talking tangentially – not unlike Patrick Sawyer’s distress. Before diagnosing him, health workers referred him to the psychosocial team. Led by Dr. Abdulaziz Mohammed, the team found that James felt he was not responding well to ORS, was deeply fearful of the outcome of his illness, and had immense anxiety. The team had to figure out if James was suffering from a psychosocial disorder or if in fact he had contracted ‘Ebola virus encephalitis,’ a brain disease that has not been thoroughly studied much less well understood. But they could diagnose only by psychological evaluation. A neurological evaluation was too dangerous to other health staff.
The team determined that James did not have brain damage because he did not display any discernable central nervous system pathology, speech defects, or convulsions. Instead, he was diagnosed with “adjustment disorder with mixed disturbances of emotion.” In addition to daily psychotherapy, he was prescribed the drug, amitriptyline, for his anxiety and lack of sleep. The psychosocial team informed the clinical staff. They also informed James’ family, and allowed them to express their own frustrations and figure out how to best manage their expectations. With this intervention, James’ anxiety and confusion were significantly reduced. Soon after, he was happily declared Ebola-free and the psychosocial team followed him for three months after his discharge.
Mr. Obinna Victor was a social worker who provided counseling in the men’s ward. “The relatives of those victims – whether suspected Ebola cases or real ones – were so much more emotionally and psychologically traumatized than the victims themselves because of the sudden confinement of their loved ones.” The biggest priority for the team was to encourage family and friends to actually visit their loved ones in the wards – something never attempted in the history of an EVD outbreak. These were viewed as key to patient survival. But it took an immense amount of work. The team shuffled between family and friends on the outside and patients in the isolation wards, making visits to each up to three times a day. “I was bringing in the information concerning someone’s wife or parents, telling the patients that their families are still very much with them and willing to come and see them, despite their condition. They were ready to share the burden.”
Two weeks after Patrick Sawyer died, the Lagos State Ministry of Health along with private partners finished their round-the-clock preparations toward setting up a new and better isolation ward. The ward’s infrastructure was designed to safely accommodate the friends and family members who were encouraged to visit. They encountered buildings with white hanging sheets that created restrictive space and increasing degrees of sensitive quarantine areas. There were signs indicating in red letters “contaminated area,” or “safe area,” as well as security ropes marking off designated footpaths. From the quarantine point of entry, family and friends followed the psychosocial team members’ footsteps into a chamber where they had to be gowned. About 4 meters away from the entry was a room where relatives and friends could come in and be given the opportunity to communicate through a protective barrier.
For those inside isolation, moving to the new ward was a huge relief. Dr. Igonoh described it as “leaving hell and going to heaven.” It was a cleaner building with better infrastructure. Patients even found brand new towels and nightwear neatly folded on the new beds. They also found that their colleagues – some who had worked alongside them to care for hospital patients at Lagos medical institutions – were now in the Ebola wards doing everything they could to save their friends. Volunteer physicians gowned up in intolerable heat and ran three shifts per day. Dr. Adesola Olalekan, a medical microbiologist and lecturer at the University of Lagos, worked as one of the phlebotomists. Like most others who volunteered, she was highly over-qualified for this task as she heads a lab on HIV research.
It is not easy to draw blood from someone with a hemorrhagic fever. Even before the needle gets inserted, bleeding can occur from anywhere even just from slight pressure. Given that this was the first outbreak in Nigeria, Dr. Olalekan and colleagues had to be trained by first shadowing WHO and MSF physicians. Then they would draw blood while being supervised. Once they got signed off, two or more people were needed to draw blood at a time. After performing multiple tasks to gown up before entering the ward, one person collects blood, while another discards and disinfects as soon as the blood is drawn. A third person is good to have on hand in case of heat exhaustion or potential accidents. Safety and contamination prevention were the highest priorities. There was a zero tolerance policy on mistakes. One car was entirely dedicated to moving samples out of the ward to the lab for analysis.
Dr. Bamidele Oke, a trained physician as well as a graduate student studying virology under Prof Omilabu, was part of a team that evaluated blood draws. All research in the virology lab came to a halt and activities were entirely dedicated to Ebola. One room was used to house and analyze blood samples. It had to be decontaminated before each use. For Dr. Oke, blood analysis wasn’t easy or straightforward. “We also looked at clinical symptoms and things like that. If someone was already vomiting but we were thinking it was a negative result, a new sample was needed.” And the process would begin again. Because the country faces chronic, daily power outages, anything could go wrong in a lab. And so, one of Dr. Oke’s activities included hunting down diesel to power the lab’s generator, which was essential to maintaining samples and running the new polymerase chain reaction machine used to identify the Ebola virus.
The move to the new ward was bittersweet. It occurred the night that the nurse, Justina Ejelonu died, on August 15. The women in the female isolation ward, including Dr. Igonoh, were completely shaken. They encouraged each other to stay positive under incredibly grim and depressing circumstances. But the following night, Dr. Stella Ameyo Adedovah, Patrick Sawyer’s chief physician who prevented him from leaving the hospital, was moved from solitary isolation to the women’s ward. Although WHO doctors were administering IV fluids and oxygen support, she was now in a coma. For Dr. Igonoh, it was unbearable to see her mentor and such a significant force at First Consultants in this state.
As Adedovah’s son, Bankole Cardos, explained, “on the first day I was able to come close and at least stand by the window and have a conversation with her. The second day, the same thing.…As everyday went on that she was there, it appeared she may pull through; and on my birthday, on a Sunday, it was the most optimistic day. Then the next day we went in and the whole story changed. They called us into a room and just explained that this is going to happen. And it’s not even a matter of days anymore. It might be hours.” She died on August 19 at the age of 57.
The media and Nigerian households celebrated Dr. Adedovah as the true heroine of the Ebola outbreak in Nigeria, as the key person who saved the rest of the country from a cataclysmic Ebola nightmare. She was the great-grand daughter and grand-niece of prominent nationalists and founders of independent Nigeria, Herbert Macauley and Nnamdi Ezikiwe. Throughout the entire country, she was spontaneously mourned in national newspapers, in religious houses, and evening vigils in a manner fitting of her family legacy.
* * *
More than anyone, Dr. Adedovah made the Emergency Operations Center’s job as easy as it could get. But the EOC still had to locate highly dispersed Ebola contacts and the question was how to engage them. An emergency presidential decree enabled health officials to access mobile phone records to use for tracing purposes, but “we learned from the other countries that this idea of calling potential contacts with the index patient wasn’t working,” recalled Dr. Nguku. Well-executed face-to-face discussions on infectious disease outbreaks tend to diffuse fear and anxiety. Phone calls have the potential to induce panic. The EOC recruited 500 “social mobilizers” and “contact tracers” – expert epidemiologists and public health officials. The contact tracers conducted daily house-to-house outreach with people who had primary or secondary contact with the index patient. The social mobilizers swept through a broad radius of the Ebola contacts in order to meet with and check on others living near those under clinical watch.
To put the massive nature of this work into perspective, the former polio EOC tracked 40,000 communities and identified over 900,000 children-recipients of the vaccine. Previous experience tracking polio included working with local community leaders and conducting polio-specific census work. When transformed to track Ebola, the tracers used apps on smart phones that collected names and their geo-coordinates. They logged body temperature and other health signs. The stats they produced showed up on a dashboard that officials could view on a big screen at the EOC. Those at the EOC headquarters could see a geographical representation of the contact tracers performing their work as it happened in real time.
At the end of the day, emergency responders called their families before arriving home. Family members took turns leaving buckets of water infused with bleach inside the front gate of their houses. Upon arrival, workers drove past the gate, parked the car, disrobed, and scrubbed down. Then they entered and resided in a separate part of the house. Unable to be in the presence of their loved ones and participate in the usual evening activities – greet their kids, help with their homework, or tuck them in bed – the bleach bucket replaced all familiar greetings throughout the emergency response.
With a critical mass of contact tracers and social mobilizers, “there was that deliberate effort to account for every contact. We were reassuring each other that this was the right approach. But a couple days into the monitoring we made a decision that the very high risk contacts needed to stay at home.” As Nguku recalls, “they would say, ‘why are you telling us to stay at home? Is it because you think we had already contracted this disease? It was high tension, high emotion. But the contact tracing staff’s nature was to say with compassion and confidence that ‘if we get you early, we treat you, we deal with the fever, we deal with the infections, and you have a better chance of survival.’ That was the basics but it took some time.” This ongoing negotiating might seem out of place for an extreme medical emergency. It was probably one of the most difficult things that the EOC conceptualized and committed to managing. More than anything, this approach was meant to avoid encouraging people to disappear off of the EOC’s radar.
But just days into the emergency response, something very frightening happened. Two contacts being monitored left Lagos. One went to Enugu, a large town in eastern Nigeria. Another went to Port Harcourt, the international city-port located in the heart of Nigeria’s oil country – the Niger Delta. Both of them ultimately tested positive for Ebola. Like Patrick Sawyer, it was never fully understood why these two left isolation. Faced with the possibility of infection, survival logics (early detection and early management) were probably being weighed against the other side of death: the potential for stigma and ostracization. Everyone knew that surviving Ebola could mean re-entering a deeply familiar world as a transformed and abandoned stranger. Running away probably seemed like a sensible action in a place where all routines and human contact suddenly ended.
Faced with these disappearances, the EOC reached out to its former polio contact tracers who lived in Enugu and Port Harcourt. They were immediately looped into the EOC. Tracers found that the nurse who left Lagos for Enugu was with her family. She was easily contacted and officials from Lagos escorted her and her husband back to the city. Contact tracers identified a total of 21 people who were immediately put under a clinical watch in Enugu. The nurse survived and luckily no Ebola infections showed up in her hometown.
But the man who escaped to Port Harcourt presented a nightmare scenario. Mr. Koye Olu-Ibukun, one of the ECOWAS diplomats who rode in the car with Patrick Sawyer on the day he arrived to Lagos, disappeared by switching off his mobile phone. According to Nigerian journalists, he confided to a colleague in Lagos that he had developed symptoms. Through this colleague, a physician located in Port Harcourt, Dr. Ikechukwu Samuel Enemuo, agreed to provide him medical care.
Port Harcourt is home to 1.9 million people and is the urban home to one of the largest delta regions in the world. The city has withstood colonial and indigenous powers duking it out for control of the rivers during the palm oil and Atlantic slave trades. These histories have morphed into current-day deadly conflicts between local communities, multinational companies, and the Nigerian military over the control of oil gushing out of the Niger Delta region. Despite the clashes, oil has a tendency to draw people everywhere into its grasp. And so along with passengers from all over Nigeria and all over the world, Mr. Olu-Ibukun boarded a flight to Port Harcourt. Once he landed, he made his way through the airport and the city. He checked into Mandate Gardens, a hotel close to Dr. Enemuo’s clinic. The physician came daily to the hotel to treat Olu-Ibukun with oral rehydration therapy. Shortly thereafter, Olu-Ibukun survived the virus. After he was relatively stable, he packed his things and left the hotel. Before Dr. Enemuo handed over the keys, he heavily doused everything in the hotel room with bleach.
Once back in Lagos, Mr. Olu-Ibukun contacted officials but did not inform them that he had survived Ebola. They were relieved and felt lucky – a high-risk contact who went off the radar appeared never to have developed symptoms. On August 26, just days after Olu-Ibukum’s return, the federal minister of health, Dr. Onyebuchi Chukwu, very happily, but cautiously, announced to media: “Ebola has been curtailed. All 129 people currently under surveillance have completed the 21-day observation period and only one person is symptomatic and being observed.”
The Minister and other health officials did not know that two weeks prior on August 11, Dr. Enemuo developed a persistent fever in Port Harcourt. He continued to see patients and he performed surgery on two of them. Soon after, his symptoms worsened and he stayed at home. At some point during these two weeks, the doctor and his wife (also a physician) held a gathering at their home to celebrate the arrival of their newborn baby. On August 16, Enemuo was admitted to the Good Heart Hospital but he apparently never disclosed that he had discretely and successfully treated an Ebola patient. He received numerous visitors including members of his church who performed a healing ritual. Over the next six days, medical staff attended to him until his death on August 22. Five days later, Prof Omilabu’s virology department in Lagos confirmed that he died of Ebola.
The day after the Minister’s announcement, the government retracted the good news. A new EOC was immediately established in Port Harcourt. As with Lagos, an isolation facility was set up; house-to-house information campaigns commenced; and radio in local languages and dialects was used to educate the public. Twenty-one contact tracing teams were also deployed to Port Harcourt. They identified 526 people who had contact with Olu-Ibukum and Enemuo. Since Olu-Ibukun made his way by flight, the passenger lists were collected and attempts were made to contact all travellers. None of them contracted EVD. Port Harcourt’s international airport was also saturated with workers screening for fevers of folks traveling within Nigeria and to other parts of the world. The tracers also had to find Ebola contacts living in nearby riverine areas, which are only accessible by boat.
The EOC discovered that the clinic where Enemuo resided never suspected Ebola until the day before the doctor died. High-level containment precautions were never taken. During his hospitalization, he shared a room with an elderly patient. His wife came for visits. His sister spent the night. Both his wife and the patient sharing a room in the hospital contracted Ebola. Dr. Enemuo’s wife survived; the patient did not.
Once the events in Port Harcourt hit the national news, many in Nigeria made calls for criminalization, forced quarantine, and the suspension of international flights. Despite the challenge of a brand new urban outbreak and the colossal logistics, the EOC refused these demands. It continued to stress the need to ensure public trust with face-to-face contacts, constant media education, and daily national briefings made by the Minister of Health. It insisted that a compassionate approach and the stories of people surviving encouraged others to seek care and trust the process.
* * *
Nigeria’s approach to combatting Ebola contrasted with how things were unfolding in Liberia, Sierra Leone, and Guinea. After a nine month-long outbreak, and two weeks after Patrick Sawyer’s arrival to Lagos, the World Health Organization finally declared a global emergency. By that time, Ebola in the Mano River region had stretched across multiple generations of contact. It began in rural areas and wasn’t ‘visible’ to authorities until it reached the cities.
In Monrovia, the capital of Liberia, government actions were not well coordinated or deployed. Attempts to reach out to communities were failing dismally. At the same time that Port Harcourt was being monitored, an isolation center was set up in the impoverished neighborhood of West Point in Monrovia – a neighborhood coping with many unattended Ebola infections. News of the center reached the neighborhood’s residents via rumor instead of official communication. In no time, very distraught folks in West Point destroyed the isolation center. The government responded by ordering security forces to seal off the community in an attempt to contain infections. Protests immediately erupted and residents clashed with the police. Even as the quarantine was lifted a week later, there was still no United Nations or WHO global plan of coordination in place – something drastically needed for a country whose infrastructure and medical expertise had long been compromised by civil war and World Bank-induced debt. In the end, the U.S. military, which had worked very closely with rebuilding Liberia’s post-war security apparatus, was called in to manage what had become a dire situation. The post-war reconstruction efforts invested massive resources in militaries and very little into health care systems, creating the logic of a militarized solution to Ebola in Liberia.
But following the 2014 U.S., British, and multiple other military deployments meant to curb the Ebola outbreak, there was a huge increase in infections. This prompted West African publics to question the usefulness of foreign military presence. It also spurred speculation on alternative motives of Western humanitarian intervention. These speculations were driven by the already existing massive foreign expropriation of diamonds, gold, iron ore, timber, and rubber, among many other natural resources extracted from the mineral rich Mano River countries. Patrick Sawyer’s employer, AcelorMettal, is one of many multinationals with economic stakes in the region. Moreover, it also coincided with foreign military ambitions after September 11, 2001. Since then millions of dollars have been invested in biodefense funding on pathogenic organisms, the building of foreign military bases, and counter-terrorism in the region. The rioting that took place in West Point can be read as pushback against agendas that leave residents forgotten amidst the priorities of resource extraction and the “War on Terror” in Africa.
While news of West Point was making international headlines, far fewer reports detailed how Nigeria eliminated Ebola. In less than 10 weeks, Nigerian heath workers screened more than 147,000 people passing through airports, attending school, and moving about in public places. The contact tracing teams identified 894 contacts with the index patient; and nearly 19,000 home visits were conducted to screen potential contacts and monitor symptoms. On October 20, 2014, the WHO declared the country Ebola-free. Nigerian health officials did not necessarily celebrate. In fact, they anticipated and waited for new infections to arrive, which fortunately never happened. But health authorities’ vigilance remained until the entire region was declared Ebola-free in July 2016.
* * *
Six days after her admittance, Dr. Igonoh’s symptoms completely cleared up. Then two days later, the fever returned leaving her perplexed. She suspected it was malaria, which strikes Nigerians as often as the common cold does in temperate climates. She decided to self-treat because during the outbreak no routine malaria testing had taken place in the ward due to safety concerns. Her boss, Dr. Ohiaeri at First Consultants, rushed anti-malarial treatment to the isolation ward. Her instincts were accurate and the fever disappeared within 2 days. She moved from drinking only ORS to eating bananas and eventually to solid bland foods. On August 16th, two weeks after she went into isolation, she tested negative for Ebola.
Dr. Igonoh left behind everything she brought with her and went for a chlorine bath. She got dressed, walked out of the bathroom and down a path toward the isolation ward’s medical staff, who were all waiting for her at the exit. She was handed a pair of scissors so that she could cut the red ribbon that led back to everything she temporarily left behind. On the other side of the cheers and hugs was her family, completely ecstatic and also Ebola-free after weeks of isolation.
In Nigeria, the only treatment that Dr. Igonoh and all others received was bottles of oral rehydration solution, aspirin, and vitamin supplements. There was no medicine in existence to treat Ebola infection. However, there were untested pharmaceuticals available. A promising treatment, ZMapp, licensed by the San Diego-based Mapp Biopharmaceuticals, was in short supply. Even though ZMapp’s efficacy and side effects were relatively unknown, it was offered as compassionate treatment to Western aid workers who got infected while combatting the epidemic. Most of those in the early stage of the infection survived Ebola.
However, at that point, no Africans had been offered ZMapp. Not even Sierra Leone’s sole virologist and hemorrhagic fever specialist, Dr. Sheikh Umar Khan, was offered ZMapp after international officials discussed his case. They were worried that if Dr. Khan died of Ebola after receiving treatment from Westerners, the potential for social unrest among an already angry Sierra Leoneon public would compromise the national response. He died on July 29, 2014. According to journalist Chernoh Bah, it was the same day that the only ZMapp dose in Sierra Leone was flown to Liberia to treat two American aid workers. Unlike Dr. Khan (who may have lapsed into unconsciousness at the time his case was discussed), they were given the choice to try the experimental drug. Two weeks later, ZMapp was flown to Liberia only because President Ellen Sirleaf requested it. By then 700 people had already been diagnosed with EVD.
In the face of these global racial divides, Nigerian officials had to rely upon their experience and expertise instead of pharmaceuticals. A total of twenty patients were diagnosed with EVD and twelve of them survived. This notable survival rate of 60% is one of the highest figures in Ebola outbreak history. This success occurred in spite of the fact that physicians were on strike, health care workers often fail to get their salaries on time (if at all), and that health care systems are dramatically underfunded and undersupplied.
The Nigerian government’s own extensive post-Ebola report explains the multiple factors that mitigated the outbreak: The determination to deeply humanize patients was decisive in curbing the outbreak. In addition to the compassion that was instilled at every level of EOC operations, it was the first time that concentrated psychosocial support was implemented into an Ebola emergency response. It was the first time ‘isolation’ got completely redefined to include uplifting visits by family members to the wards, which were essential to survival. The insistence that widespread public trust was possible – even when that trust got undermined in Port Harcourt – was also pivotal in controlling the outbreak.
After the Ebola emergency abated, two hundred Nigerian volunteers travelled to the Mano River States to help contain Ebola infections there. But most responders returned to their normal duties. For some, it was the usual lab work, university lecturing, and seeing patients. For others, it was attending to chronically reoccurring emergencies. Francisca Nwaokorie, who helped with the Lagos Ebola education programs, returned to Benue State in Nigeria’s Middle Belt where a cholera outbreak was under way across since 2012 – an emergency that requires attention to sanitations systems not scheduled for overhauls any time soon. Moreover, Dr. Nguku’s pioneering work on polio vaccination resumed when the virus unfortunately resurfaced again in 2016. Efforts to contain polio still remain hampered by the insecurity and difficult-to-detect movement of over 2 million internally displaced people as a result of terrorist activity in northeast Nigeria. And Dr. Adedovah’s family recently established The Dr. Ameyo Stella Adadevoh Health Trust, which works to curb infectious disease and improve Nigerian health care systems.
The Nigerian response was recognized as a model for future Ebola emergency outbreaks – an achievement that came with both pride and sadness. As Dr. Igonoh stated at a Lagos press conference that featured the governor and most Ebola survivors, “we are privileged to see this day, to be here with everybody, it’s an honor. … We remember the people that we lost, the wonderful people who risked their lives. We will never forget them. We can’t. Our lives have been changed. And every one of us who went through this ordeal, we know that we are better for it.”
Dr. Ohiaeri, CEO of First Consultants Medical Centre, center, with all of his staff who survived Ebola.
Kris Peterson is an anthropologist based at the University of California Irvine. She has conducted ethnographic research in Nigeria since 2000 and is the author of the award winning book, Speculative Markets: Drug Circuits and Derivative Life in Nigeria (Duke University Press, 2014). Along with Morenike Folayan and Aminu Yakabu (among others), she has published several articles and commentary on the Ebola outbreak in West Africa.
Morenike Oluwatoyin Folayan is Reader at Obafemi Awolowo University in Ile-Ife, Nigeria, where she works in the Department of Child Dental Health. She also serves as the deputy director of the College of Health Sciences Research & Partnership Advancement (CoRPA) and is the head of the Health Professions Development Unit at OAU’s Institute of Public Health. Additionally she pursues HIV and other health-related advocacy work with many community-based organizations including the New HIV Vaccine and Microbicide Advocacy Society, located in Nigeria.
Aminu Yakubu holds a masters in public health from the University of Birmingham. He formerly worked as a research officer at the Nigerian Federal Ministry of Health, where he specialized in clinical ethics. He currently is a public communications officer at Nigerian Centre for Disease Control, which responds to disease outbreaks in Nigeria.